ATI RN MED
SURG
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse
obtained a verbal prescription for
... [Show More] restraints. Which of the following should the actions the nurse take?
Document the client's condition every 15 minutes
A nursing planning care for a school-age child who is 4 hr postoperative following perforated
appendicitis. Which of the following actions should the nurse include in the plan of care?
Administer analgesics on a scheduled basis for the first 24 hr
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should
the nurse plan to assess first?
a client who has a hip fracture and a new onset of tachypnea
A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions
should the nurse take?
Wear gloves to apply the patch to the client's skin
A nurse hasjust received change-of-shift report for four clients. Which of the following clients should
the nurse assess first?
a client who was just given a glass of orange juice for a low blood glucose level
a nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following
places the client at risk for aspiration?
a history of gastroesophageal reflux disease
A nurse is reviewing the laboratory results for a client who has cushing's disease. The nurse should
expect the client to have an increase in which of the following laboratory values?
Serum glucose level
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate
intravenously. The nurse discontinuesthe magnesium sulfate after the client displacestoxicity. which of
the following actions should the nurse take?
Administer calcium gluconate iv
A charge nurse is teaching new staff members about factors that increase a client's risk to become
violent. Which of the following risk factors should the nurse include as the best predictor of future
violence?
Previous violent behavior
A nurse is preparing to perform a sterile dressing change. Which of the following actions should the
nurse take when setting up the sterile field?
Place the cap from the solution sterile side up on clean surface
A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which
of the following instructions should the nurse include?
Eat a light snack before bedtime
A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of
the following actions should the nurse take first?
identify environmental hazards in the home
A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the
following questions should the nurse ask the client?
"what high school did you graduate from?"
A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following
goals should the nurse include in the teaching?
Hba1c level less than 7%
A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a
new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the
client develops ataxia and incoordination?
The client is showing evidence of phenytoin toxicity
a nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following
manifestations requires immediate action by the nurse?
increase in frequency ofswallowing
A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of
the following interventions should the nurse include in the plan of care?
Monitor the child's cardiac status
A nurse is planning an educational program for high school students about cigarette smoking. Which of
the following potential consequences of smoking is most likely to discourage adolescents from using
tobacco?
Use of tobacco decreases the level of athletic ability
A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values
should the nurse monitor for this client?
Serum potassium
A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse.
Which of the following statements by the nurse indicates an understanding of this role?
"i will let the client know that i am available asthe interpreter."
A nurse is performing assessments on newbornsin the nursery. Which of the following findings should
the nurse report to the provider?
A two day old newborn who has a respiratory rate of 70
A nurse on an acute unit has received change ofshift report for 4 clients. Which of the following clients
should the nurse assess first?
A client who hasfractured left tibia and pallor in the affected extremity
A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which
of the following adverse effects should the nurse instruct the client to report to the provider?
Shuffling gait
A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the
following instructions should the nurse plan to include in the teaching?
Keep the cord stump dry until it falls off
A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food
choices is appropriate for the client?
Potato pancakes
A nurse is working in acute care mental health facility is assessing a client who hasschizophrenia. Which
of the following findings should the nurse expect?
Disorganized speech
A nurse is caring for a client who is immobile which of the following interventions is appropriate to
prevent contracture?
Apply an orthotic to the client's foot
A public health nurse working in a rural area is developing a program to improve health for the local
population. Which of the following actions should the nurse plan to take?
Provide anticipatory guidance classes to parentsthrough public schools
A nurse in the emergency department is performing triage for multiple clients following a disaster in the
community. To which of the following types of injuriesshould the nurse assign the highest priority?
Below the knee amputation
A nurse is preparing a change ofshift report for an adult female client who is postoperative. Which of
the following client information should the nurse include in the report?
Platelets 100,000/mm3
A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding?
Prealbumin 10 mcg/dl
A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (lpn)
who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the
following client assignments should the nurse delegate to the lpn?
A client who is postoperative following a bowel resection with an NGT set to continuous suction
A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction.
The nurse notes early deceleration on the fetal heart rate monitor. Which of the following nursing
actions should the nurse take?
Continue the monitor the fetal heart rate
A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients
current iv infusion and the information received during the shift report. Which of the following actions
should the nurse take?
Compare the current infusion with the prescription in the client's medication record.
A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which
of the following findings should the nurse identify as a contraindication to the administration of
clozapine?
WBC count 2,900 /mm3
A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis c. The client
asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is
appropriate?
You may breastfeed unless your nipples are cracked or bleeding.
A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral
resection of the prostate. Which of the following should the nurse identify as priority nursing assessment
after reviewing the client's information? Exhibit.
Level of consciousness
A nurse is caring for a client who has hyperthermia. Which of the following actions for the nurse to take?
Initiate seizure precautions
A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the
nurse include?
Document the client's conditions every 15 minutes
A nurse in emergency department is caring for a client who has full thickness burn of the thorax and
upper torso. Aftersecuring the client's airway, which of the following isthe nurse's priority intervention?
Initiating iv fluid resuscitation
A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's
daughter tells the nurse, "i'm not sure what to say to my mom if she asks me about dying." Which of the
following responses by the nurse is appropriate? (SATA)
-Let's talk about your mom's cancer and how things will progress from here.
-Tell me how you are feeling about your mom dying.
-You sound like you have questions about your mom dying. Let's talk about it.
A nurse is reviewing the medical records of four clients. The nurse should identify that which of the
following client findings require follow up care?
A client who received a Mantoux test 48 hours ago and has induration
A community health nurse receives a referral for a family home visit. Which of the following tasks should
the nurse perform first?
Clarify the source of the referral
A nurse is caring for a client who will undergo a procedure. The client states he does not want the
provider to discuss the results with his partner. Which of the following is an appropriate response for the
nurse to make?
You have the right to decide who receives information
A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an
original weight of 90.7 kg (200 lb). The nurse should identify the weight of the following total
percentage?
7.5%
A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the
following interventions should the nurse implement?
Pour water from a squeeze bottle over the client's perineal area.
A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25
mcg/hr transdermal patch. Which of the following instructions should the nurse include in the teaching?
Avoid hot tub while wearing the patch
A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client
has an area of non-blanchable erythema over his ischium. Which of the following interventions should
the nurse include in the care plan?
Teach the client to shift his weight every 15 min while sitting.
A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the
therapeutic relationship. Which of the following statementsshould the nurse make during this phase?
We should establish our roles in the initialsession.
A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse
should instruct the client that it is safe to eat which of the following foods while taking this medication?
Whole grain bread
A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of
steps the nurse should take. (move the steps into the box on the right, placing them in the selected order
of performance. Use all steps)
Transport the client to another area of the nursing unit (1)
Activate the facility’s fire alarm system(2)
Close all near by windows and doors(3)
Use the unit’s fire extinguisher to attempt to put out the fire (4)
A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the
nurse expect?
Heightened perceptual field
A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling
well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (select
all that apply.)
Tremors
Diaphoresis
Inability to concentrate
A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse
identify as an expected finding?
Weak femoral pulses
A community health nurse is planning primary prevention activities to reduce the occurrence of abuse.
Which of the following strategies should the nurse include in the plan?
Teach parenting skills to families at risk for abuse
A nurse and an assistive personnel (ap) are caring for a group of clients. Which of the following tasks is
appropriate for the nurse to delegate to the ap?
Applying a condom catheter for a client who has a spinal cord injury
A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following
statements by the client indicates an understanding of the teaching?
"I will avoid food and beveragesthat contain caffeine"
A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which
of the following is an appropriate action by the nurse?
Provide humidification of the room air
A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive
personnel?
Perform chest compressions during cardiac resuscitation
A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu.
The nurse should recognize which of the following findings as a potential contraindication for using
lavender?
The client has a history of asthma
A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline.
The nurse should monitor for which of the following adverse effects?
Urinary retention
A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the
following disorders is a contraindication for oral contraceptive use?
Hypertension
A nurse is preparing to witness a client's signature on a consent form for a colon resection. The nurse
should recognize that which of the following information should be provided to the client by the
provider before signing the form? (SATA)
A. Explain the procedure
B. Expected outcome of the procedure
C. Potential complications
D. Possible alternative treatments
A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan.
Which of the following statements is appropriate to include in the teaching?
"you should not have this procedure if you are allergic to iodine."
A nurse in a provider's office is reviewing a female client's medical record during a routine visit. The
nurse should recommend increasing dietary intake of which of the following vitamins? (exhibit) - h&p:
postmenopausal, hx dvt and iron deficiency anemia, works indoors, consumes 1-2 alcoholic beverages
per week.
Vitamin D
A nurse is caring for a child who has sickle cell anemia and experiencing vaso-constrictive crisis. Which of
the following actions should the nurse include in the plan of care?
Initiate IV fluid replacement
A nurse is teaching a parent about safety securing her 3-month-old infant in a carseat. Which of the
following images indicates that the parent understands the teaching?
B - Image with the middle clasp at the armpits of the baby
A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1
unit of packed rbcs. Which of the following actions should the nurse take?
Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion
A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the
facility against medical advice. After notifying the provider, which of the following actions is appropriate
for the nurse to take?
Explain the risks of leaving
A nurse is making an initial postpartum home visit. Which of the following client statements should the
nurse identify as a manifestation of increased risk for child abuse?
"i think the baby should be sleeping through the night by now.
A nurse is caring for an infant who has gastroenteritis. Which of the following assessments should the
nurse report to the provider?
Sunken fontanels and dry mucous membranes
A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse
does not speak the same language as the client. The client's partner and a 10-year-old child are
accompanying her. Which of the following actions should the nurse take to gather the client's
information?
Request a female translator interpreter through the facility
A nurse is caring for a client who has pernicious anemia, which of the following laboratory values should
the nurse evaluate effectiveness of the treatment?
Vitamin B12 level
A nurse is assigning tasks to assistive personnel (AP). Which of the following tasks should the nurse
assign to the AP?
Perform postmortem care
A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following
findings should indicate to the nurse that the client's ability to eliminate urine from the bladder is
restored?
Two voids of 150 ml each over the past 2 hours
A nurse is caring for a client who has acute glomerulonephritis. Which of the following should the nurse
expect?
Hematuria
A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following
effects should the nurse include?
Excessive sweating
A nurse is providing teaching to the parents of a newborn about genetic screening. Which of the
following statements should the nurse include in the teaching?
This test should be performed after your baby is 24 hours old
A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following
actions should the nurse take?
Perform the procedure twice a day
A nurse is preparing an in service for a group of nurses about malpractice issues in nursing. Which of the
following examples should the nurse include in the teaching?
Administering potassium via IV bolus
A nurse in a clinic is assessing a client who reports frequent headaches. Identify the area the nurse
should palpate to check the client's maxillary sinus for tenderness.
(Picture is man looking to the left the area where you should click is just below the right eye near the
nose box) Palpate the maxillary sinuses by pressing upward at the skin crevices that run from the sides of
the nose to the corner of the mouth.
A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should
the nurse instruct the client to take prior to initiating postural drainage?
Use an albuterol inhaler
A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the
following actions should the nurse take?
Monitor the dorsalis pedis pulse every 15 minutes
A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of the
following actions should the nurse take?
Offer high-calorie, high protein snacks to the client
A nurse is caring for a client who requests to ambulate in the hallway with his own clothing. The nurse is
demonstrating which of the following ethical principles when respecting the client's decision to wear his
own clothing?
Autonomy
A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which
of the following actions should the nurse take first?
Check the mouth for soot and smoky breath
A nurse is assessing a client who had heart failure and is taking furosemide. Which of the following
findings should the nurse monitor?
Hyponatremia
A nurse is caring for a client who weighs 75 kg. The client has a prescription from a dietician to decrease
calorie intake by 500 cal/day for 25 weeks to produce a weight loss of 1 pound per week. What is the
expected goal weight for the client in pounds at the end of the 25 weeks? (round the answer to the
nearest whole number. Use leading zero if it applies. No trailing zero)
140 pounds
1 lb per week x 25 week= 25 lbs 75 x 2.2= 165 lbs165 lbs-25 lbs=140 lbs
A nurse is providing discharge teaching about circumcision care to a parent of a newborn. Which of the
following statements by the parent indicates an understanding of the teaching?
I will change my baby's diaper at least every 4 hours
A home health nurse is caring for an adult client who reports, "I keep coughing when I try to swallow my
food, but not at other times." Which of the following actions should the nurse take?
Initiate a consultation with a speech language pathologist
A nurse is caring for a client who is insulin dependent and is undergoing tests to determine if his blood
glucose is being adequately controlled. The nurse should identify that which of the following laboratory
values is the best indicator of adequate blood glucose control?
HbA1C 6.5%
A nurse is planning to administer atenolol to a client. Which of the following should the nurse assess
prior to administering the medication?
Blood pressure
A nurse is orienting a newly licensed nurse while caring for clients who are in labor. Which of the
following pain management strategies by the newly licensed nurse requires intervention?
Placing a transcutaneous electrical nerve stimulation (tens) unit on a client’s abdomen
A nurse hasidentified tasksto delegate to a group of assistive personnel (AP) after receiving change-ofshift report. Identify the sequence ofsteps the nurse should follow when delegating tasks to the aps.
Review the skill level of and qualifications of each AP
Communicate appropriate tasksto the APs with specific expectations
Monitor progress of task completion with each AP
Evaluate the APs performance of each task
A nurse is teaching a prenatal class about infection prevention at a community center. Which of the
following statements by a client indicates an understanding of the teaching?
"I can visit my nephew who has chickenpox 5 days after the sores have crusted."
A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. the
nurse observes blood on the child's dressing. Which of the following actions should the nurse take?
Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site.
A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy
for a foot injury. Which of the following findings should the nurse identify as a contraindication for heat
therapy?
Peripheral neuropathy (loss ofsensation- r/f burns)
A nurse is providing teaching to a client who is to undergo a cardiac catheterization. Which of the
following findings is expected during the procedure?
Sensation ofskin warmth
A nurse is transcribing new medication prescriptions for a group of clients. For which of the following
prescriptions should the nurse contact the provider for clarification?
Lorazepam .5 mg PO one tablet daily
A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the
provider. which of the following findings should the nurse include in the teaching?
Swelling of the face (preeclampsia)
A nurse is providing care for a client who has esophageal cancer and hasreceived radiation therapy.
which of the following findings should the nurse identify as the priority?
Dysphagia
A nurse is assessing a client who is 2 hrs postpartum for uterine atony. Which of the following action
should the nurse take?
Palpate the client'sfundus
A school nurse is teaching a parent about absence seizures. which of the following information should
the nurse include?
"thistype ofseizure can be mistaken for daydreaming"
A nurse in a surgicalsuite is planning care for a client who requiressurgery and has a latex sensitivity.
which of the following is appropriate for this client?
Tape stockinet over monitoring device and cords
A nurse is reviewing the medical record of a client. The nurse should identify that the client is at risk for
which of the following complication. (exhibit)
Dumping syndrome
A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the
following action should nurse take? (SATA)
Wear a lead apron when providing care
Limit visitors to 30 mins
Close the door to the client's room
A charge nurse is providing teaching for group of newly licensed nurse about grieving process. Which of
the following information should the charge nurse include in the teaching?
Client might feel guilt over some aspect of their loss
A client who is pregnant voices her concern that her 3-year-old son will feel left out when the newborn
arrives. Which of the following statements by the nurse is appropriate?
Offer your son a gift when the baby receives one
A nurse is obtaining a nutritional health hx on a client who reports problems with constipation. Which of
the following should the nurse identify as a cause of constipation?
New prescription for an iron supplement
A nurse is assessing a newborn who has patent ductus arteriosus. Which of the following findings should
the nurse except?
Bounding pulse
a nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium
sulfate via continuous iv infusion. Which of the following actions should the nurse include in the plan?
Measure the client's urine output every hour.
a nurse is caring for a client who has end stage kidney disease. The client's adult child asks the nurse
about becoming a living kidney donor for her father. Which of the following conditions in the child's
medical history should the nurse identify as a contraindication to the procedure?
Hypertension
a nurse is caring for a client who has COPD and is 5kg (11lb) below her ideal body weight. The client
experiences shortness of breath when eating. Which of the following actions should the nurse take?
Request non gas forming foods from the dietary department.
a nurse in a provider's office is reviewing the laboratory results of a group of clients. The nurse should
identify that which of the following sexually transmitted infectious disease that should be reported to
the state health department?
Chlamydia
a nurse is reviewing the laboratory findings of a client who is receiving IV infusion of insulin. The client's
lab findings reveal a potassium level of 5.5 meq/l, BUN of 15 mg/dl, and a creatinine level of 1 mg/dl.
Which of the following interventions is appropriate for the nurse to take?
Place a cardiac monitor on the client
a nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a
detached retina. Which of the following statements by the client indicates an understanding of the
teaching?
I can resume activities, such as sewing.
a nurse is planning to administer vancomycin iv to a client. Which of the following actions should the
nurse take to reduce the risk of an adverse reaction to the vancomycin?
Give the dose over 60 min
a nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving
hemodialysis. Which of the following instructions should the nurse include in the teaching?
Eat 1g/kg of protein per day
a nurse is delegating tasks to an assistive personnel caring for a group of clients. Which of the following
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